Considered a "fringe" therapy 25 years ago, biofeedback has matured today to a
modality much closer to mainstream treatment. Its value is accepted by a growing
number of professionals, and it is covered by Medicare for some conditions, as well
as by most health insurers.
Applied psychophysiology has yet to fulfill early enthusiastic predictions of the
benefits of learning and applying self-regulatory skills. However, the field has
amassed sufficient research and clinical data to justify an important secondary role
in treating a number of specific disorders. Fueled by advances in technology and
increasing interest in alternative therapies, biofeedback remains a dynamic force that
continues to tantalize with possible-though as yet unproved-applications.
Biofeedback, also referred to as applied psychophysiological feedback, is the
process of displaying involuntary or subthreshold physiological processes, usually
by electronic instrumentation, and learning to voluntarily influence those processes
by making changes in cognition. It provides a visible and experiential demonstration
of the mind-body connection. Biofeedback is also a therapeutic tool to facilitate
learning self-regulation of autonomic functions for improving health.
In a quiet room, seated in a comfortable chair with sensors attached to the skin, the
trainee (patient) views a monitor. Advances in hardware and software technologies
allow simultaneous monitoring of multiple modalities and the flexible shaping of
visual and sound feedback to reinforce desired physiological states. Extensive data
can be collected for immediate display with automatic storage for research.
There are six commonly employed feedback modalities:
Electromyographic (EMG): Frontalis, masseter, trapezius and sternocleidomastoid
are the most frequently monitored sites.
Skin Conductance Level (SCL): Also referred to as Galvanic Skin Response (GSR).
Finger electrodes register sweat gland activity.
Thermal: Finger thermistors measure vasoconstriction by minute changes in
peripheral blood flow.
Respiratory: Strain gauges measure abdominal and thoracic excursions; a
capnometer monitors exhaled CO2.
Heart Rate (HR): Finger photoplethysmography registers rate and pulse volume.
Brainwave/Neurofeedback (EEG): Multichannel equipment with more sophisticated
software and new treatment protocols have replaced the simple single channel alpha
training of earlier decades.
Biofeedback Applications
Used alone as relaxation therapy, biofeedback is as efficacious as other forms of
relaxation training, such as hypnosis, progressive muscle relaxation or
transcendental meditation. However, most applications of biofeedback are used as
adjuncts to other types of therapy, treating physiological as well as psychological
disorders.
Physiological disorders with credible research to support the ancillary use of
biofeedback include headaches, chronic pain, rheumatoid arthritis, asthma,
temporomandibular joint disorders, dysmenorrhea, epilepsy, hypertension, irritable
bowel syndrome, intestinal motility, motion sickness, neuromuscular rehabilitation,
Raynaud's disease and fecal incontinence (Crabtree et al., 1995; Schwartz, 1995).
Biofeedback also seems to be a useful tool in the treatment of a broad range of
problems commonly seen by psychiatrists. The adjunctive use of biofeedback is
reasonably well-documented for the psychological disorders of anxiety and
insomnia. Many forms of psychotherapy, including dynamic, behavioral and brief,
appear to have enhanced efficacy when biofeedback-assisted. Both the patient and
therapist benefit from a display of physiological responses, which can help identify
resistance, denial and other defense mechanisms. Biofeedback monitoring can
provide a uniquely vivid demonstration of the connection between thoughts and
feelings. Brain wave feedback is showing promise in the treatment of attentiondeficit/hyperactivity disorder, addictive disorders and posttraumatic stress disorder
(PTSD).
Biofeedback and GAD
Anxiety in some form is a problem that all psychiatrists must deal with on a daily
basis. It is one of the most frequently observed categories of emotional disorders in
the American population and often seriously interferes with the quality of everyday
life. All of the anxiety disorders are defined by the dual characteristics of
physiologic hyperarousal and excessive emotional fear.
Biofeedback has demonstrated value for hyperarousal reduction training in
generalized anxiety disorder (GAD) and exposure desensitization in panic disorder
(PD) and PTSD.
Multimodal cognitive/behavioral therapy (CBT), which may include biofeedback,
offers an equally effective alternative to medications, particularly for patients who
do not respond well, who have a potential for dependency or who refuse prescription
drugs. Optimum treatment outcome for GAD and PD is more likely to be achieved
with a combination of pharmacotherapy and CBT.
Biofeedback is one of the most useful adjuncts in treating physiologic hyperarousalboth episodic and chronic-seen in anxiety disorders. It has also proved helpful for
patients who are learning to reduce fearful anticipation triggers through
cognitive/behavior therapies.
Biofeedback training is a part of the behavioral treatment, which includes relaxation
training, because of its additional specificity. Biofeedback offers a
nonpharmacological approach to direct symptom reduction and can be tailored to the
individual patient's psychophysiological profile. Those patients experiencing
symptoms of muscle tension have EMG sensors attached to muscle sites showing
the highest activity. Patients with mainly autonomic symptoms generally receive
thermal, GSR, heart rate and respiration feedback. EEG feedback may be useful
when an assessment documents brain wave pattern dysregulation.
Behavioral treatment may also include cognitive interventions to identify negative
thinking, and to develop more appropriate assessment of life events. Where specific
fears can be identified, behavioral fear reduction techniques, such as desensitization,
modeling or flooding, may be used. Concomitant use of biofeedback may enhance
the therapeutic effectiveness of these techniques. Like most behavioral treatments,
biofeedback is most effective with patients willing to assume an active role in the
treatment process, including home practice.
Most studies document improvement and significant symptom reduction in six to 12
sessions of biofeedback training, with more complex or chronic patients requiring
more sessions. For instance, in 1993 Rice et al. studied 45 GAD subjects (38 of
whom met the DSM-III criteria). The study subjects were randomized to four
treatment groups: frontal EMG biofeedback, EEG alpha enhancement biofeedback,
EEG alpha suppression biofeedback or a pseudomeditation control. Results were
compared against wait-list controls. All treated subjects showed significant
reductions in STAI-Trait Anxiety and psychophysiological symptoms on the
Psychosomatic Symptom Checklist. Decreased self-report of anxiety was
maintained at six weeks posttreatment.
CBT, Biofeedback and Panic
David H. Barlow, Ph.D., developed a comprehensive model of panic disorder in
which he explained that panics were sustained in patients because they developed a
fear of bodily sensations associated with panic attacks (1988). Anxious
apprehension causes chronic increased autonomic arousal, which increases vigilance
with heightened sensitivity to evermore minute body sensations. A vicious cycle of
apprehension and physiological activation results in panic disorder.
By allowing heightened internal awareness, low arousal relaxation training may
actually precipitate increased anxiety in some patients with panic disorder. This
relaxation-induced anxiety is less likely to occur with biofeedback than other
general relaxation procedures.
Diagnostic accuracy increases when biofeedback is used to monitor physiological
reactions to questions about anxiety. EMG, SCL, HR, temperature and respiration
are measured. The treatment of PD with CBT has four components, each of which
may be more effective with biofeedback. Three focus on managing panic; the fourth
aims to eliminate it.
Educational, Informational: Patients learn the causes of panic, the "fear of fear"
cycle and the rationale for treatment. Various biofeedback modalities help in
experiencing and understanding on a gut level the relationship between thoughts,
feelings, images, bodily sensations and the actual body responses. "Biofeedback
information seems to help patients 'get it' a lot faster," noted Hugh Baras, Ph.D.,
reporting on a study of biofeedback and panic disorder presented at the recent 24th
Annual Conference of the Biofeedback Society of California in Monterey, Calif.
Somatic Management Strategies: Patients use these techniques to manage anxious
apprehension. They include diaphragmatic breathing retraining, slow breathing and
muscle relaxation. "Biofeedback-assisted breathing retraining and biofeedbackassisted muscle relaxation can be very helpful in providing motivation for patients
and in providing the experience of mastery over their panic reactions," reported
Baras.
Cognitive Restructuring: This technique provides instruction and practice in
constructive self-talk to reduce fears of anxiety sensations. Exaggerated fears of
somatic symptoms or the probability of negative reactions and adverse outcomes are
replaced with more realistic attitudes. Trainees are often surprised to see the
biofeedback equipment demonstrate a striking difference between the responses
from their fearful thoughts as compared to responses as a result of their restructured
thoughts.
Fear Exposure Strategies: The aim of these strategies is to eliminate the experience
of panic. They are also the nonpharmacological treatment of choice for specific
phobias, including agoraphobia and obsessive-compulsive disorder. In a systematic
and controlled way, exposure therapy elicits the physical sensations that trigger
anxiety. The goal-fear extinction-is to break the associations between increased
body sensations and panic reactions. There are two types of fear exposure:
1. Brief and graduated (systematic desensitization): The arousal-provoking event is
presented for about a minute, spaced with intervals of relaxation. The intensity of
arousal is gradually increased, creating the experience of anxiety mastery.
2. Prolonged and intense (flooding): Ten to 15 minutes of repeated exposure to
maximal intensity stimulus demonstrates to the patient that the feared negative
consequences do not occur. This results in fear extinction. Exercises to help induce
flooding include rapid head movements, breath holding, restricted breathing,
hyperventilation and muscle tensing.
Substantial research data support the value of using cognitive restructuring and fear
exposure in preventing relapse. Like a pilot turning on the radar, exposure therapy is
more effective when therapist and patient have immediate autonomic feedback to
guide the process. The advantages of biofeedback-assisted CBT for PD include
increased awareness and control of the stress response, increased motivation for
treatment and willingness to practice home assignments, and heightened selfconfidence.
Biofeedback for Children
There are several controlled studies showing the efficacy of using biofeedback to
reduce anxiety in children. In 1996, Wenck et al. studied 150 seventh- and eighthgraders identified as anxious by their teachers. The students were randomly assigned
to biofeedback intervention, which included six sessions each of EMG and thermal
biofeedback, or control groups. The researchers found that the biofeedback group
had significantly lower posttest states and trait anxiety.
Referrals and Certification
Biofeedback therapy is commonly performed by clinical psychologists, or by a
biofeedback trainer under the direct supervision of a psychologist or psychiatrist.
The Biofeedback Certification Institute of America has a written/practicum
certification process. The Association for Applied Psychophysiology and
Biofeedback in Wheat Ridge, Colo., sponsors an annual conference and provides
information and referrals. Larger states have biofeedback societies for local
referrals.
Dr. Brauer has been certified since 1976 by the Biofeedback Certification Institute
of America and is the founder and director of TotalCare Medical Center in Palo
Alto, Calif. He is clinical assistant professor, department of psychiatry and
behavioral sciences, Stanford University and was founder of the university's
Biofeedback and Stress Reduction Clinic.
References
Barlow DH (1988), Anxiety and Its Disorders: The Nature and Treatment of
Anxiety and Panic. New York: Guilford Press.
Crabtree M, Kase J, Bland A et al. (1995), An Annotated Bibliography on Clinical
Applications of Biofeedback and Applied Psychophysiology. Wheat Ridge, Colo.:
Association for Applied Psychophysiology and Biofeedback.
Rice KM, Blanchard EB, Purcell M (1993), Biofeedback treatments of generalized
anxiety disorder: preliminary results. Biofeedback Self Regul 18(2):93-105.
Schwartz MS (1995), Biofeedback: A Practitioner's Guide. New York: Guilford
Press.
Wenck LS, Leu PW, D'Amato RC (1996), Evaluating the efficacy of a biofeedback
intervention to reduce children's anxiety. J Clin Psychol 52(4):469-473.
Enable Javascript to correctly view this page.
Send this page to a friend
Get information about obtaining a printed copy of this publication.
For inquiries specific to this document, refer to the volume/issue date at the top of this page.
Permission to repost or reprint any material on this site must be obtained by contacting the
Webmaster.
Select Your Destination-->
Webmaster
Copyright 1995-2005 CME LLC
Terms of Service.
go